In a 6-month follow-up study of 119 hospitalized adolescents, Yen and colleagues found that many traditional risk factors including psychiatric diagnoses and past attempts failed to prospectively predict suicidal behavior. Other factors, which the authors called "cross-cutting" (because they cut across many disorders) were more potent.

These findings have direct clinical implications and indirect prevention implications. From a clinical perspective, clinicians must be cautious in applying population-generated risk factors to clinical risk formulation. Clinical training in risk formulation should emphasize dynamic factors over diagnoses and history and involve thoughtful synthesis of a wide range of factors and individual circumstances. From a broader prevention perspective, the study provides additional building blocks in the argument for focusing on cross-cutting constructs such as emotion self-regulation in suicide prevention (see our recent population-based study identifying emotion self-regulation as a critical construct for youth suicide prevention). This emphasis on "cross-cutting" constructs has interesting intersections with NIMH's effort, represented by the Research Domain Criteria (RDoC) to shift research away from DSM diagnostic categories toward dimensional assessment of more fundamental and biologically verifiable constructs. These findings are also congruent with (though they do not directly support) strategies that reach further "upstream" in adolescent development to build core "cross-cutting" protective factors.

The New York Times published an article this week that readers of this blog should be aware of. The article is titled, Study Questions Effectiveness of Therapy for Suicidal Teenagers. The article reports on results from a study published in JAMA Psychiatry (the new name for Archives of General Psychiatry) by Matthew Nock and a team of outstanding scientists. The NYT headline is based mostly on the finding that:

...suicidal adolescents typically enter treatment before rather than after the onset of suicidal behaviors. This means that mental health professionals are not simply meeting with adolescents in response to their suicidal thoughts or behaviors, but that adolescents who are clinically severe enough to become suicidal more typically enter treatment before the onset of suicidal behaviors. There is no way to know from the NCS-A data how often this early intervention prevents the occurrence of suicidal behaviors that would otherwise have occurred but were not observed in our data. It is clear, though, that treatment does not always succeed in this way because the adolescents in the NCS-A who received treatment prior to their first attempt went on to make an attempt anyway. This finding is consistent with recent data highlighting the difficulty of reducing suicidal thoughts and behaviors among adolescents. (Nock et al, (2013) Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents, JAMA Psychiatry, ePub ahead of print, p. E9)

The Nock article is hefty and I have not yet fully digested it. So I will withhold judgement about the article's conclusions, and about whether the NYT article reported them fairly and accurately. However, I am pleased about the discussions that this study and the Times article have the potential to stimulate. One conversation is about how to improve the quality and effectiveness of treatment for at-risk adolescents. This is not a new conversation, but continues to be an important one. Another conversation I hope this NYT article will stimulate relates to broadening our view of what suicide prevention is. With some important exceptions (including some here in New York State), the dominant strategy in suicide prevention has been to identify youth who are suicidal and get them into treatment. As my mentor, Peter Wyman has demonstrated (Wyman et al, 2008) and this Nock article brings to the surface, these 'identify and refer' strategies are limited by a number of factors, including availability and acceptability of services, the length of time adolescents remain in services, the effectiveness of therapy, and adolescents' tendency not to disclose suicide concerns to adults (Pisani et al 2012). While I am committed as ever to improving the quality of screening, assessment, and treatment for at-risk adolescents (and help to train hundreds of clinicians each year), I do not expect that treatment services alone will be sufficient for reducing suicide in the population. For this reason, in my research I am pursuing youth suicide prevention strategies aimed at addressing risk and protective processes further "upstream" (a term I learned from Dr. Wyman). In an article soon to be published, I argue that we need new interventions that can flexibly reach a broader population of adolescents further upstream and that these will require making use of new delivery systems, designs, and technologies.

I look forward to studying the Nock article and to participating a discussion that could help stimulate the field to re-examine what "prevention" really means. Substance abuse prevention does not start with finding kids who are already taking drugs. Fire prevention doesn't start with the fire department. We need great fire departments and well-trained fire fighters, but fire protection engineering and public education make major conflagrations rare. Likewise, youth suicide prevention must focus more broadly then on adolescents who are already suicidal.

Clinicians, school personnel, parents and other adults share at least one thing in common: none of us can read minds. The only way we're going to know if an adolescent is considering suicide is if they tell us. My colleagues and I conducted a study examining some key correlates of help-seeking among adolescents who had seriously considered suicide. The results have been published in the Journal of Youth and Adolescence.

The small island of Nantucket, MA has seen 3 teen suicides in a short period of time, according to the New York Times. Very sad. Statistically, three suicides in a high school of 400 represents a meaningful cluster, and a possible contagion effect. Whether it is or it isn't contagion in Nantucket (it is impossible to know for sure and the article suggests some disagreement in this case), the key thing for clinicians to know is that vulnerability to contagion has been documented in adolescents. Clinicians working with adolescents at risk at the time of a public or peer suicide should consider reassessing their clients' risk for suicide when news of a peer death becomes public.

This NYT article about 14 year-old boy who died on Wednesday after critically wounding a teacher and classmates, is a case study in risk for adolescent suicide. Abuse/neglect history, legal trouble, access to weapons, social misfit, recent disciplinary action at school. The temporal proximity of his older brother's arrest is also striking...again pointing to the systemic properties of suicide.

There is a lot of material available about assessing for risk of suicide in adolescents, but much less that focuses on small children. Some cases are relatively (and I mean relatively) straightforward, like the child who says he is going to kill himself in anger when he doesn't get his way. But I have seen a fair number of young children where it is more complicated. Some of them may express the suicidality in anger, but they also take actions like grabbing a kitchen knife or putting shoelace around their necks and pulling it.

Now, in all of the cases I have seen this action has been taken in full view of parents or other adults, which makes it somewhat less concerning (at least in terms of immediate risk for suicide), but nevertheless the child has taken an action which, if done at another time and in a slightly different way could be dangerous.

Our frameworks for assessing risk in adults fall short in these cases. I know I feel on less steady ground. If anyone knows of good resources--ones that not only provide risk factors, but ways of conceptualizing suicidal behavior in young children, I'd love to hear from you.